Yes! I’d Like to Schedule a FREE “Launchpad To Success” Strategy Session.

Thank you for requesting a complimentary “Launchpad to Success” Strategy Session. I look forward to setting a small amount of time aside each month to meet with families who are considering academic life coaching as a next step to success.

Because my time is limited, and coaching is only successful if the student is a willing participant, I will only consider applications that have been filled out by the student. However, the parent may ALSO fill out this survey so that I can have access to both parties’ perspectives on the issues.

All information is completely private and confidential. I’ll be in touch soon to let you know about next steps!

* Required

Email address *

Your email

Who is filling out this form? *

Parent

Student

Student and Parent Together

Other:

What is your city, state, and time zone? *

Your answer

How did you find out about my services? *

Your answer

How does the student feel about the idea of receiving coaching? *

Relieved and ready for help

Open but cautious

Resistant and/or wary

The student doesn't know about it yet

Other:

Your Contact Information, Please:

Student's First and Last Name *

Your answer

Student's Year/Grade Level *

Your answer

Student's Email Address *

Your answer

Student's Cell Phone Number

Your answer

Parents' Names

List the name of any parents who might be communicating with me.

Your answer

Parents' Phone Numbers

List the preferred phone number first and then any alternative numbers.

Your answer

Parents' Email Addresses

List the preferred email address first and then any alternative emails.

Your answer

What video-chat applications does the student know how to use, or is willing to learn? *

Skype

FaceTime

Google Hangouts

Zoom

Other:

Required

Please provide the address for the student's preferred form of video chat. *

For Skype, give the username. For FaceTime or Google Hangouts, give the relevant email address and/or phone number. For Zoom, simply indicate that the student has Zoom installed on their computer and can use it.

Your answer

Now, Tell Me More About You...

What are the student's strengths, special skills, hobbies, and interests? *

What activities make you feel happy and energized? Please be as specific and complete as possible. Part of making this process work for you is having more of the good in your life, so I want to know what that is for you.

Your answer

What is the student's single biggest struggle or challenge with school with which you would like help? *

Please be as specific and complete as possible.The more I know, the more I can figure out the best methods of helping you succeed.

Your answer

What struggles or challenges in life are contributing to stress at school? *

Sometimes stress in other areas of our lives contributes to our stress at school. Bullying, conflict with a sibling, depression, a recent household move, and other problems can all make school stress worse. It's okay if you're not comfortable sharing details, but the more I know about your stressors, the more I can help you with your school challenges.

Your answer

What specific issues would you like addressed by academic life coaching? *

Time Management

Organization

Study Skills

Writing

Clear Communication With Parents

Self-Advocacy With Teachers

Reading Comprehension

Note Taking

Testing Anxiety

Planning Ahead/Thinking Ahead

Lack of Motivation

Initiating/Starting Work

Procrastination

Trying Too Hard

Self-Esteem

Perfectionism

Other:

Required

Please describe the grades you are currently earning. *

To what extent are these grades causing stress for you?

Your answer

Why are you serious NOW about taking action to improve your school experience? *

Your answer

Has the student been tested for learning differences/disabilities? *

If so, please list the date of the testing, the psychologist who did the test, and a few notes about the results of the testing.

Your answer

Finally: What is YOUR Commitment Level to Your Academic Success?

Please answer these questions from the perspective of the person filling out the form. If you are the STUDENT, what is your commitment level in each of the following areas? If you are the PARENT, what is yours?

How much ENERGY are you willing to put towards your success in school? *

Very low

1

2

3

4

5

6

7

8

9

10

Very high

How much TIME are you willing to put towards your success in school? *

Very low

1

2

3

4

5

6

7

8

9

10

Very high

To be answered by the person responsible for paying for coaching: *

People always ask me how much they will need to invest into coaching, so let me take the hype out of it. Realistically, unless you are considering a group program, you should be able to invest between $1500 and $2500 per semester for one-to-one coaching with me. How willing and able are you to make that level of investment without causing undue financial hardship?

Major hardship

1

2

3

4

5

6

7

8

9

10

No hardship

What else would you like me to know about your situation and/or commitment level before we schedule a meeting?

Your answer

Would you like to begin receiving my newsletter, which has quick tips about how to study more effectively and links to my longer articles about specific study issues?

If YES, please indicate which email address to send them to. I strongly recommend starting your coaching NOW with this free resource; please know you can unsubscribe any time you need to.

Your answer

That's All I Need To Know!

When you submit this form, you'll see a second link to schedule your free "Launchpad to Success" session. I look forward to meeting you!